Provider Demographics
NPI:1720154560
Name:KRALOVANSKY, JERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:KRALOVANSKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-2142
Mailing Address - Country:US
Mailing Address - Phone:574-936-2272
Mailing Address - Fax:574-936-1283
Practice Address - Street 1:109 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-2142
Practice Address - Country:US
Practice Address - Phone:574-936-2272
Practice Address - Fax:574-936-1283
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT34900Medicare UPIN
IN511300Medicare ID - Type Unspecified